Post-Acute and Long-Term Care Patients Account for a Disproportionately High Number of Adverse Events in the Emergency Department

2020 ◽  
Author(s):  
Richard T. Griffey ◽  
Ryan M. Schneider ◽  
Lee Adler ◽  
Alexandre Todorov
Keyword(s):  
Emergency Department ◽  
Adverse Events ◽  
Long Term Care ◽  
Term Care

scholarly journals LO15: Paramedic and allied health professional interventions at long-term care facilities to reduce emergency department visits: systematic review

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S12-S12
Author(s):  
S. Leduc ◽  
Z. Cantor ◽  
P. Kelly ◽  
V. Thiruganasambandamoorthy ◽  
G. Wells ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Health Professionals ◽  
Allied Health ◽  
Long Term Care ◽  
Allied Health Professionals ◽  
Term Care ◽  
Ed Visits

Introduction: Emergency department (ED) crowding, long waits for care, and paramedic offload delay are of increasing concern. Older adults living in long-term care (LTC) are more likely to utilize the ED and are vulnerable to adverse events. We sought to identify existing programs that seek to avoid ED visits from LTC facilities where allied health professionals are the primary providers of the intervention and, to evaluate their efficacy and safety. Methods: We completed this systematic review based on a protocol we published apriori and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. Two investigators independently selected studies and extracted data using a piloted standardized form and evaluated the risk of bias of included studies. We report a narrative synthesis grouped by intervention categories. Results: We reviewed 11,176 abstracts and included 22 studies. Most studies were observational and few assessed patient safety. We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Of the 13 studies that reported ED visits, all (100%) reported a decrease, and of the 16/17 that reported hospitalization, 94.1% reported a decrease. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. When measured, studies reported decreased hospital length of stay, more time spent with patients by allied health professionals and cost savings. Conclusion: We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. Many identified programs focused on improved primary care for patients. Interventions addressing acute care issues such as those provided by community paramedics, patient preferences, and quality of life indicators all deserve more study.

Abstract W P340: Emergency Department Nurses Collaborate With Long Term Care Facilities for Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jamie L Strom
Keyword(s):  
Emergency Department ◽  
Long Term Care ◽  
Stroke Patients ◽  
Term Care ◽  
Stroke Treatment ◽  
Emergency Department Nurses ◽  
Senior Services ◽  
To Receive ◽  
Education Initiative

Background and Purpose: Stroke treatment is often delayed before patients reach the emergency department (ED). Some patients arrive in time to receive medication that can reverse new stroke symptoms. Some are not as fortunate. They are either admitted to the palliative unit, or discharged only to live with their new disabilities possibly for the rest of their lives. In 2013, nurses observed many long term care (LTC) patients were not getting to the ED in time to receive tPA (tissue plasminogen activator), a medication used to reverse stroke symptoms. The purpose of this process improvement was to increase the number of LTC patients with stroke symptoms arriving in the ED within the tPA window. Methods: To determine how many patients from nursing homes were missing the tPA window, data from the ED’s records was abstracted from the month of June 2013. The sample size was all patients who presented with possible stroke symptoms, and who were also from LTC facilities. Surprisingly, 100% of LTC patients presenting with stroke symptoms missed the tPA window. With the support of ED leadership, we decided to raise awareness about the tPA window in the LTC facilities. No evidence existed from ED’s related to LTC patients and the tPA window. Approximately 1,000 unused stroke pamphlets were collected. A PowerPoint presentation based on AHA guidelines was used. A lecture occurred at the community’s senior services meeting, and many LTC administrators were willing to adopt this education initiative at their facilities. ED staff became involved and helped conduct the in-services. In exchange for their volunteering, they received credit to help with career ladders at their hospital. Results: The number of possible stroke patients from LTC facilities getting to the ED within eight hours of the last time seen normal (LTSN) has increased from 0% in June 2013, to 25% in March 2014. Conclusions: Stroke education teams of ED nurses showed improvement in LTC patients arriving in the ED within the tPA window. In conclusion, it is encouraged that other ED staff volunteer to teach in LTC facilities in their own communities, in assisting their stroke patients as well.

scholarly journals 1442. Effect of Reflex Urine Culturing on Rates of Cultures and Infections in an Acute Care Hospital, Emergency Department, and Two Long-Term Care Facilities

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S526-S526
Author(s):  
Chelsea Lynch ◽  
Andrea Appleby-Sigler ◽  
Jacqueline Bork ◽  
Rohini Dave ◽  
Kimberly C Claeys ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Long Term Care ◽  
White Blood Cells ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Post Intervention ◽  
Term Care ◽  
Absolute Increase

Abstract Background Urine cultures are often positive in the absence of urinary tract infection (UTI) leading to unnecessary antibiotics. Reflex culturing decreases unnecessary urine culturing in acute care settings but the benefit in other settings is unknown. Methods This was a quasi-experimental study performed at a health system consisting of an acute care hospital, an emergency department (ED), and two long-term care (LTC) facilities. Reflex urine criterion was a urine analysis with > 10 white blood cells/high-power field. Urine cultures performed per 100 bed days of care (BDOC) were compared pre- (August 2016 to July 2017) vs. post-intervention (August 2017 to August 2018) using interrupted time series regression. Catheter-associated UTI (CAUTI) rates were reviewed to determine potential CAUTIs that would have been prevented. Results In acute care, pre-intervention, 894 cultures were performed (3.6 cultures/100 BDOC). Post-intervention, 965 urine cultures were ordered and 507 cultures were performed (1.8 cultures/100 BDOC). Reflex culturing resulted in an immediate 49% decrease in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.8/1000 catheter days and 1.6/1000 catheter days post-intervention. Reflex culturing would have prevented 4/14 CAUTIs. In ED, pre-intervention, 1393 cultures were performed (5.4 cultures/100 visits). Post-intervention, 1959 urine cultures were ordered and 917 were performed (3.3 cultures/100 visits). Reflex culturing resulted in an immediate 47% decrease in cultures performed (P = 0.0015). In LTC, pre-intervention, 257 cultures were performed (0.4 cultures/100 BDOC). Post-intervention, 432 urine cultures were ordered and 354 were performed (0.5 cultures/100 BDOC). Reflex culturing resulted in an immediate 75% increase in cultures performed (P < 0.001). The CAUTI rate 2 years pre-intervention was 1.0/1000 catheter days vs. 1.6/1,000 catheter days post-intervention. Reflex culturing would have prevented 1/13 CAUTIs. Conclusion Reflex culturing canceled 16%-51% of cultures ordered with greatest impact in acute care and the ED and a small absolute increase in LTC. CAUTI rates did not change although reflex culturing would have prevented 29% of CAUTIs in acute care and 8% in LTC. Disclosures All authors: No reported disclosures.

The Impact of Long-term Care Facility Bed Availability on Emergency Department Overcrowding

2007 ◽  
Vol 14 (5 Supplement 1) ◽  
pp. S84-S85
Author(s):  
J. Fan ◽  
A. Al-Darrab ◽  
M. McIssac ◽  
A. Worster ◽  
S. Upadhye ◽  
...  
Keyword(s):  
Emergency Department ◽  
Long Term Care ◽  
Care Facility ◽  
Term Care ◽  
Emergency Department Overcrowding ◽  
Term Care Facility ◽  
Long Term Care Facility ◽  
The Impact

Understanding Acute Care Usage by Adult Chronically Critically Ill Ventilated Patients: A Chart Review

2020 ◽  
Vol 14 (3) ◽  
pp. 123-129
Author(s):  
Sarah Crowe ◽  
A. Fuchsia Howard ◽  
Gregory Haljan
Keyword(s):  
Emergency Department ◽  
Critically Ill ◽  
Acute Care ◽  
Residential Care ◽  
Long Term Care ◽  
Emergency Department Visits ◽  
Term Care ◽  
Residential Care Facility ◽  
Chronically Critically Ill

ObjectivesTo better understand the rationale for acute care usage among long term care ventilated residents.BackgroundChronically critically ill ventilated individuals experience complex health challenges, with many not surviving one year post initial hospitalization discharge. Recent research reports high acute care readmission rates for chronically critically ill patients, yet most studies have not examined the reasons patients are readmitted, nor the treatment and care provided during these stays.MethodA retrospective medical chart reviews of all emergency department visits and acute care admissions, occurring from August 2014 to August 2016, of chronically critically ill ventilated individuals living in a residential care facility in the province of British Columbia, Canada was conducted.ResultsThere were 49 emergency department visits and 56 acute care admissions over a 2 year period by 20 chronically critically ill ventilated residential care patients. The majority of acute care admissions were related to pneumonia, whereas the majority of emergency department visits were not specified.ConclusionChronically critically ill ventilated long term care residents are high users of acute care resources, frequently admitted for pneumonia.

scholarly journals LO65: Frailty and associated outcomes among emergency department patients requiring endotracheal intubation

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S31
Author(s):  
S. Fernando ◽  
D. McIsaac ◽  
B. Rochwerg ◽  
S. Bagshaw ◽  
A. Seely ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mechanical Ventilation ◽  
Hospital Mortality ◽  
Endotracheal Intubation ◽  
Resource Utilization ◽  
Long Term Care ◽  
Clinical State ◽  
Term Care ◽  
The Impact

Introduction: Risk-stratification of patients requiring endotracheal intubation and mechanical ventilation in the Emergency Department (ED) is necessary for informed discussions with patients regarding goals-of-care. Frailty is a clinical state characterized by reduced physiologic reserve, and resulting from accumulation of physiological stresses and comorbid disease. Frailty is increasingly being identified as an important independent predictor of outcome among critically ill patients. Our objective was to identify the impact of clinical frailty (defined by the Clinical Frailty Scale [CFS]) on in-hospital mortality and resource utilization of ED patients requiring endotracheal intubation and mechanical ventilation. Methods: We analyzed a prospectively collected registry (2011-2016) of patients requiring endotracheal intubation in the ED at two academic hospitals and six community hospitals. We included all patients ≥18 years of age, who survived to the point of ICU admission. All patient information, outcomes, and resource utilization were stored in the registry. CFS scores were obtained through chart abstraction by two blinded reviewers. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). We defined “frailty” as a CFS ≥ 5. Results: 4,622 patients were included. Mean age was 61.2 years (SD: 17.5), and 2,614 (56.6%) were male. Frailty was associated with increased risk of in-hospital mortality, as compared to those who were not frail (adjusted odds ratio [OR] 2.21 [1.98-2.51]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted OR 1.78 [1.56-2.01]) among patients initially from a home setting. Frail patients were more likely to fail extubation during their hospitalization (adjusted OR 1.81 [1.67-1.95]) and were more likely to require tracheostomy (adjusted OR 1.41 [1.34-1.49]). Conclusion: Presence of frailty among ED patients requiring endotracheal intubation and mechanical ventilation was associated with increased in-hospital mortality, discharge to long-term care, extubation failure, and tracheostomy. ED physicians should consider the impact of frailty on patient outcomes, and discuss associated prognosis with patients prior to intubation.

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